A Hospice Transitions Program for Patients in the Emergency Department

Key Points Question Is a multidisciplinary program aimed at the timely identification and transition of eligible patients presenting near the end of life to the emergency department associated with a significant increase in goal-concordant hospice care? Findings In this quality improvement study, 61 of 270 patients (22.6%) achieved the primary outcome of goal-concordant transition to hospice within 96 hours in the control period compared with 210 of 388 (54.1%) in the intervention period. In addition, the presence of a Medical Order for Life-Sustaining Treatment was independently associated with hospice transition across all groups (adjusted odds ratio, 1.88; 95% CI, 1.18-2.99). Meaning Hospitals can investigate the implementation of a similar hospice transition program to improve use of hospice at their institutions.


Screening and Identification
Screening for potential candidates occurs via natural language processing via Admit-Discharge-Transfer Health Level Seven (ADT HL7) feeds and case-by-case screening by clinical staff.Natural language processing code was written de novo by our information services "data lake team."The code is a simple string-matching approach using either exact phrases or regular expressions to identify diagnosis codes attached to the ADT HL7 feed.Results are refreshed every 15 minutes and alerts are sent to emergency department (ED) care facilitator staff via automated email for patients with neurological or cancer diagnoses.ED care facilitators are expected to review each email alert during their shift and reply with patient eligibility.The full code may be requested from our data lake team.
Individual case screening was interdisciplinary, largely led by ED clinicians and care facilitators.All clinical teams were educated to identify patients who presented from hospice or are likely to transition to hospice within 96 hours as potential pathway patients.These general criteria are intentionally left broad to allow for clinical correlation on a case-by-case basis.All patients identified as potential candidates are sent to the ED care facilitator for formal screening, which is a key component of the intervention.If eligible for the pathway, the ED care facilitator will alert the admitting team to the appropriate level of care and discuss whether hospice referrals are appropriate.If not eligible, the patients receive routine care, including palliative care services as appropriate.The ED care facilitators document their screening summary in a note template in the electronic health record (EHR) consisting of a brief patient history, whether they are eligible for the pathway, and whether hospice referrals are placed.

Modified Workflows and Education
Provider workflows, initially a barrier to hospice utilization due to a cumbersome EHRbased admission process, were a focus of improvement.Working with admitting, compliance, medical records, revenue cycle, and information services, we streamlined the EHR-based admission process.Furthermore, the revenue cycle team reviews each hospice pathway enrolled patient to ensure that there is no impact on out-of-pocket patient costs.
Education is a key driver of pathway performance.Over twenty interprofessional clinical teams are educated at least biannually by operational leads (ML and LMO); these teams include ED nurses, advanced practice providers, attendings, trainees, nurse care coordinators, specialty clinicians (attendings, advanced practice providers, trainees), palliative care and nursing staff.
Education sessions are approximately 15 minutes long, typically at least twice a year, and consist of an overview of hospice and services offered, pathway workflow logistics, patient feedback and experience data, and case examples.Education is reinforced continuously via workflow graphics and tip sheets created to meet the needs of various provider settings and role groups.
Printed copies are posted in key work areas and contain QR codes to digital tip sheets.A patientfacing brochure providing an overview of hospice and the services available was created in partnership with a multidisciplinary team, including a patient-family advocate, hospital staff, and hospice vendors.

Data Tracking and Reporting
At the time of program implementation, reports were created to capture all patients who were discharged to hospice or expired in the hospital.These reports help facilitate weekly case reviews with interprofessional pathway stakeholders, including utilization management, ED care facilitators and inpatient case managers, case management leadership, palliative care, frontline clinical champions (neuroscience and oncology medical leadership), and operational leaders.At each weekly review meeting, all reported cases are classified as eligible and hospice pathway enrolled, eligible and hospice pathway not enrolled, or ineligible and recorded on a master patient tracker that allows for graphical representations of progress and an ability to identify trends quickly.Providers caring for patients who were deemed eligible and hospice pathway not enrolled receive email feedback, which has been helpful in identifying barriers to pathway utilization or educational gaps.Weekly enrollment reports are sent to pathway steering committee members, consisting of key institutional stakeholders and divisional and executive leadership.Steering committee meetings are held monthly to provide updates on progress and identify barriers.

New Hospice Vendor Relationships
When launching the program, new hospice vendor relationships were pursued to expand access to patients seeking hospice services.At the time of contracting, mutually agreed-upon performance metrics were created for each vendor, including time to patient admission and length of stay.Hospice note templates were created in alignment with both vendors to standardize the documentation process in our EHR, allowing for improved communication.The operational leads meet monthly with each vendor to identify successes and opportunities.

eFigure 1 .
Abbreviations: ED (Emergency Department); EHR (Electronic Health Record) For Patients with Cancer, Multivariate Logistic Regression Model for Primary Outcome of Patient Transitioning from the ED to Hospice Within 96 Hours Without Admission For Patients with Neurologic Diagnoses, Multivariate Logistic Regression Model for Primary Outcome of Patient Transitioning from the ED to Hospice Within 96 Hours Without Admission © 2024 Baugh CW et al.JAMA Network Open.